The Integrated Multimorbidity Care Model is being implemented in five pilot sites from Spain (the Andalusian Health System and the Aragon Health System), Lithuania (Vilnius University Hospital Santaros Klinikos, VULSK, Vilnius and Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Kauno Klinikos, Kaunas), and Italy (Università Cattolica del Sacro Cuore (UCSC), Rome). As described in the methods section, a survey was carried out at the start of the project to identify characteristics of the participating centers before the implementation of the Integrated Multimorbidity Care Model. Results of the survey revealed some common goals for the five pilot sites, such as to increase multidisciplinary collaboration, promote evidence-based practice, and reduce inequalities in access to care and support services. A summary of some of the characteristics of the sites is illustrated in Table 3
. All five pilot sites include a six-month run-in period (patient recruitment), followed by a 12-month implementation period. Key indicators are measured at the end of the implementation. JA CHRODIS-PLUS is a three-year project and the timescale of the interventions were chosen in order to allow sufficient time for preparation, application of the intervention, and reporting. Most of the implementers considered it important to involve general practitioners and nurses in delivering care to patients. Indeed, the majority of patients are being identified via primary care settings. In all cases, the main care providers are either general practitioner physicians or nurses (or they are involved in the multidisciplinary meetings). Case managers are appointed in the majority of interventions (usually a physician) and many also include a social worker as part of the core multidisciplinary team. All five sites report that their patients will undergo comprehensive assessment at the start and end of the integrated care process, but few include a regular periodic assessment in-between. Most of the programs reported some key common characteristics of the intervention and services, patient education, follow-up visits, and referrals between medical specialties have been reported by all five sites, and clinical (diagnostic/monitoring) tests in all but one. However, other characteristics of the intervention and services differ somewhat between settings.
Most sites are using technology in their interventions. For example, four of the five sites offer eHealth services and half of the multidisciplinary team meetings are conducted virtually. All five sites reported using digital health care communication tools; these are mostly e-referral but there are also other aspects like virtual conferences with patients and online appointment schedules. Three-quarters of the sites have electronic systems for registering/monitoring care processes and all use electronic health records. However, currently none of the programs use electronic decision support systems. The survey also highlighted some noticeable absences, especially in terms of community and social resources. In fact, only one site is directly supporting patients in accessing community and social resources.
3.2. Description of Pilot Sites
The Andalusian Health System: “Implementation of a ‘personalized action plan’ within the strategy and comprehensive plan for complex chronic patients”.
The “Consejería de Salud y Familias de la Junta de Andalucía” is implementing their Integrated Multimorbidity Care Model in primary care centers all over this region of Spain. The implementation is linked with the healthcare strategy for complex chronic patients, within the framework of the Andalusian comprehensive healthcare plan for patients with chronic diseases. The plan focuses on enhancing community care (primary healthcare), intra-level coordination, and continuity of care (using a liaison nurse). The objectives of the care model are to: increase multidisciplinary collaboration, improve patients and informal careers involvement, improve functional status, decrease and delay complications, to reduce inequalities in access to care and support services, and reduce hospital admissions and acute care visits. The intervention targets one component of the Integrated Multimorbidity Care Model (see Table 4
), namely individualized care plans, although other components of the model are already in place. The specific aim of the intervention is to assess the influence of the systematized application of individualized and comprehensive care plans to complex chronic patients (patients with chronic severe health problems, multimorbidity, and polypharmacy). All complex chronic patients with individualized care plans started and delivered between December 2018 and February 2019 were selected as the target population and will be followed for one year. Regular training of healthcare professionals is provided through the OPIMEC platform [16
The Aragon Health System: “Aragon primary care”.
The model is being implemented in a total of 13 primary health care centers in the Aragon Health System. A total of 43 healthcare professionals (21 general practitioners, 18 primary care nurses, 2 internal medicine specialists, and 2 internal medicine nurses) from 13 health care centers and 1 hospital, with a long professional experience, have been trained in multimorbidity through the eMulti-PAP course developed within the framework of the Multi-PAP randomized control trial [17
]. A total of 291 high risk multimorbid patients from their respective practices have been selected and included in the piloting. The main aim is to examine the feasibility of implementing this type of intervention in a real context and to decrease the impact of multimorbidity on health outcomes in patients aged 65 years and over with multimorbidity (≥3 chronic diseases) and polypharmacy (≥5 drugs). The main objectives of the care model are to: promote evidence-based practice, reduce inequalities in access to care and support services, prevent or reduce misuse of services, increase multidisciplinary collaboration, and decrease morbidity. The intervention targets eleven components of the Integrated Multimorbidity Care Model (see Table 4
) from all domains. They include training for healthcare providers, appointment of a case manager, use of individualized care plans, development of a virtual inter-consultation system, and supporting access to community resources.
UCSC-Rome outpatient clinic in the Catholic University of the Sacred Heart, Rome, Italy: “Multimorbidity care model in elders with dementia and adults with intellectual disability”.
UCSC-Rome are implementing their model in a national health service run tertiary care hospital (Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli) in Rome, Italy. The clinical government unit is mainly involved in this project together with the center for ageing medicine (Centro Medicina dell’Invecchiamento). The care model is carried out in a day hospital and focuses on ageing, frail patients with intellectual disability, comorbidity/multimorbidity, and cognitive impairment. The aim of the intervention is to improve coordination and provide patients with a reference care provider as well as to increase accessibility of care through a Technocare service and enhance self-management through patient-operated technology. The main objectives of the care model are to: improve professional knowledge on multimorbidity, reduce inequalities in access to care and support services, improve accessibility of services, improve care coordination and integration of different units (within the organization), increase multidisciplinary collaboration, identifying target group patients, improve patient and informal career involvement, and reduce hospital admissions and acute care visits. The intervention will target nine components of the Integrated Multimorbidity Care Model (see Table 4
), from all five domains.
Kauno Klinikos: Kauno clinics primary healthcare center and Kaltinenai primary healthcare center, Kaunas, Lithuania.
Kauno Klinikos is implementing the care model in the family medicine department of a tertiary university clinic located in the second largest Lithuanian city. It provides all scope of primary care services and is in close relation with other health sectors: secondary and tertiary as well. The target population includes patients with multimorbidity aged 45–70, identified by GPs. The aim of the intervention is to test the Integrated Multimorbidity Care Model patients in Lithuania to provide better care for multimorbid patients and improve their quality of life, decrease the number of potentially avoidable hospitalizations and readmissions, to elaborate economical evaluation of the expenditure for the multimorbid patients. The main objectives are to: reduce adverse outcomes related to the presence of multiple diseases and the risk of drug-drug interactions by elaborating individualized integrated care plans, optimize treatment, maintenance, and healthcare resources by coordinating individualized integrated care plans; maximize outcomes and increase continuity of care while decreasing fragmentation and optimizing access to care and services through a case manager, who will intermediate between a patient and various members of the multidisciplinary team; provide doctor-to-doctor decision support in situations where further clinical support or knowledge is needed outside of the core team through a consultation system to be advised by professional experts; and improve the patient‘s access to community resources, formal care, and patient associations, support groups, and psychosocial support by providing multidisciplinary care both in terms of different levels of the healthcare profession (nurses, physicians, physiotherapists, social workers etc.), and different disease specializations. The intervention targets 13 components of the Integrated Multimorbidity Care Model (see Table 4
), from all five domains.
VULSK family medicine center primary care setting at Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania: “Family medicine center, primary care”.
VULSK is implementing the care model in primary care but is also expanding beyond the primary care setting, to include the secondary and tertiary care physicians, aiming to create teams who manage the patient. It is aimed at multimorbid patients attending primary care settings. The main objective of the program is to promote evidence-based practice to primary care multimorbid patients with the aim to improve their quality of life, decrease the number of potentially avoidable hospitalizations and readmissions, and elaborate economical evaluation of the expenditure for the multimorbid patients. The intervention targets 10 components of the Integrated Multimorbidity Care Model (see Table 4
) from all five domains. In particular, it includes all components from the delivery of care model and the decision support components. The specific aims of the intervention include to: (1) Reduce adverse outcomes related to the presence of multiple diseases and the risk of drug-drug interactions by elaborating individualized integrated care plans; (2) optimize treatment, maintenance, and healthcare resources by coordinating individualized integrated care plan; (3) maximize outcomes and increase continuity of care while decreasing fragmentation and optimizing access to care and services through a case manager; (4) provide doctor-to-doctor decision support in situations where further clinical support or knowledge is needed outside of the core team through a consultation system of professional experts; (5) improve the patient‘s access to community resources, formal care, and patient associations, support groups, and psychosocial support by providing multidisciplinary care both in terms of different levels of the healthcare profession and different disease specializations.